LIST OF WITNESSES.

A. E. Brindley, Esq., M.D., B.Sc., D.P.H. Medical Officer of Health, Derby. Joint Lecturer on Public Health, University of Manchester. John Brownlee, Esq., M.A., D.Sc., D.P.H. Director of the Statistical Department, National Institute for Medical Research. (Since deceased.)

A. F. Cameron, Esq., M.A., M.D., D.P.H. Medical Superintendent, River Hospitals and Ambulance Service, Metropolitan Asylums Board. Captain S. R. Douglas, M.R.C.S., F.R.S., I.M.S. (retd.) Director of the Department of Experimental Pathology and Bacteriology, National Institute for Medical Research.

A. Drury, Esq., M.B., C.M. Public Vaccinator, Halifax Union. (Since deceased.)

R. P. Garrow, Esq., M.D., D.P.H. Medical Officer of Health, Chesterfield. Major-General D. S. Harvey, C.M.G., C.B.E., M.D. Director of Patho logy, War Office.

R. W. Jameson, Esq., M.D., M.R.C.S., D.P.H. Late Assistant Medical Officer for smallpox purposes, Gloucester.

C. Killick Millard, Esq., M.D., D.Sc. Medical Officer of Health, Leicester.

Wm. McConnel Wanklyn, Esq., M.R.C.S., D.P.H. Assistant Medical Officer, London County Council. Consultant in diagnosis of smallpox, London, Middlesex and Essex County Councils.

CONTENTS.

PART I.

Page.

Reference i:

On matters relating to the preparation, testing and standardi-
sation of vaccine lymph

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The Royal Commission and the use of calf lymph

The origin of vaccine lymph

Maintenance of quality

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9

9

9

11

12

12

The Government Lymph Establishment technique and procedure at,
Technique of vaccine lymph production in other countries...
International co-operation

On the practical methods which are available in the light of
modern knowledge to diminish or remove any risks which
may result from vaccination

Brief review of the work of the Royal Commission
Summary of the recommendations of the Royal Commission
Vaccination administration in England and Wales ...
Comparison of alleged ill-effects of vaccination before and after
the Vaccination Act, 1898

Table I.-England and Wales. Table showing the number of
primary infantile vaccinations and deaths from vaccinia at
all ages and under one year from 1875 to 1925 inclusive ...
Table II.-Comparison of the deaths associated with vaccina-
tion in the two periods, 1886-1891 and 1911-1925

The appearance of diseases of the central nervous system
Inquiries into the subsequent medical histories of recently vac-
cinated persons
Investigations over a period of three months into the medical his-
tories of a number of recently-vaccinated children and adults,
vaccinated at their own homes, and of a similar number of
controls
Observations over a period of three months into the medical his-
tories of boys vaccinated at a residential school ...
Observations over a period of one month into the medical histories
of 206 adults vaccinated at a time when suffering from certain
specified injuries or diseases

24

On the methods of vaccination which are most appropriate to
give protection against risk of smallpox infection in epidemic
and non-epidemic periods

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The clinical course of primary vaccinia in the resting adult male.
Relation between the severity of the general reaction as indi-
cated by the temperature and that of the local reaction as shown
by the extent of the area of redness and of the vesicular area ...
Effect of exercise on recently vaccinated adult males ...
The relative severity of primary vaccination in six insertions and
in two insertions of young adult males at rest
The comparative values of rubbing lymph into the incisions and
of merely applying it to them
The present state of vaccination
General considerations

...

PART II.

DISEASES OF THE CENTRAL NERVOUS SYSTEM FOLLOWING VACCINATION

Report of the Committee presided over by Sir Frederick Andrewes (May, 1925)

89

90

129

...

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Particulars of cases considered by the Andrewes Committee
Sequence of events between the end of the period covered by the
Report of the Andrewes Committee, May, 1925, and the date
of appointment of the present Committee, February, 1926
The epidemiology of reported cases of "post-vaccinal "diseases of
the central nervous system occurring in the period 1st January,
1926-30th September, 1927, England and Wales
Time and place incidence
Age and sex incidence: duration of illness, fatality
Relation between the cases and (1) lymph issued to public
vaccinators, (2) the incidence of poliomyelitis and polioen-
cephalitis, (3) the incidence of encephalitis lethargica, and
(4) of smallpox

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...

...

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145

146

Vaccination of cases: primary or secondary, lymph used
Clinical characteristics
Table VIII.-Reports on the subsequent histories of certain cases
considered by the Andrewes Committee

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A brief comparison of certain epidemiological features common to the British and Dutch cases

150

150

The hypothesis of activation of a neurotropic virus by the virus
of vaccinia

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A commentary on the Report of the Andrewes Committee
The theory of fortuity
The hypothesis that vaccinia is the sole cause of post-vaccinal
encephalitis

...

Experimental data bearing on the problem of post-vaccinal encephalitis.

Analysis of certain recorded data

On the possibility of producing fatal encephalitis or other
lethal issue by inoculation of vaccine virus elsewhere than in
the brain of experimental animals
Demonstration of vaccine virus or other virus in the brains
of fatal human cases of post-vaccinal encephalitis

The mutual interaction of viruses. Ad hoc experiments
Summary of experiments carried out by members of the Andrewes
Committee and by this Committee
Demonstration of vaccine virus in the brains of fatal human

cases

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...

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Demonstration of vaccine virus in organs and central nervous
system of cutaneously inoculated animals

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Experiments on rabbits and monkeys with a view to demon-
strating the presence of virus or viruses other than vaccinia
in the brain tissue of fatal human cases ...
Experiments in connection with the question of interaction
between concomitant virus infections
Brief summary of experimental data

Summary and recommendations...

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Experimental studies of vaccinia virus in relation to encephalitis.
Memorandum by Mervyn H. Gordon, C.M.G., C.B.E., F.R.S.,
M.D.

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Page.

192

194

197

199

203

APPENDICES.

PART I.

Appendix 1.-Particulars of deaths returned as "41 (1) Vaccinia" in the Registrar-General's Statistical Review, 1911-1925.

Appendix II.-Particulars of cases, including deaths, associated with vaccination, but not returned as "41 (1) Vaccinia" in the RegistrarGeneral's Statistical Review, 1911-1925.

Appendix III.-An inquiry into illnesses occurring within three months after vaccination in vaccinated cases and in unvaccinated controls, by George F. Buchan, M.D., M.R.C.P., D.P.H.

Appendix IV.-Report on the result of the analysis of the post-vaccinal medical history of 753 boys in a residential institution.

Appendix V.-Observations on the vaccination of adult males.

Appendix VI.—The clinical course of primary vaccination in the resting adult (with three charts).

Appendix VII.-Table showing the relationship between the severity of the general reaction as indicated by the temperature and that of the local reaction as shown by the extent of the area of redness and the vesicular area.

Appendix VIII.-Chart to contrast the highest four-hourly temperature of 24 hours in men resting with that of men doing two hours' physical exercise daily.

Appendix IX.-Chart to contrast the rate of development of the vesicles in men resting with that of men doing two hours' physical exercise daily.

Appendix X.-Tables and charts to contrast the average daily area of areola and vesicles, and the average daily maximum temperature in six-mark and two-mark vaccinations.

Appendix XI.-Tables and charts to contrast the average daily area of areola and vesicles, and the average daily maximum temperature in Type 1 and Type II inoculations.

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PART II.

Appendix XII.-Diagram showing (1) lymph issued for public vaccination, (2) number of cases of poliomyelitis and polio-encephalitis, (3) number of cases of encephalitis lethargica, and (4) number of cases of smallpox, in relation to the six cases of "post-vaccinal" diseases of the central nervous system which were reported in 1924 and 1925. Appendix XIII.-Summary of information received since the publication of the Committee's request in the medical press in April, 1926. Appendix XIV.-Chart showing time incidence of 25 cases of " 'postvaccinal" diseases of the central nervous system.

Appendix XV.-Diagram showing details as in Appendix XII in relation to the 25 cases of "post-vaccinal" diseases of the central nervous system which were reported January, 1926-October, 1927. Appendix XVI.-Table showing the relation between the single cases of " post-vaccinal" diseases of the central nervous system and the notifications of (1) poliomyelitis and polio-encephalitis, (2) encephalitis lethargica and (3) smallpox from the same sanitary districts. Appendix XVII.-Sheffield C.B. and certain urban districts in Monmouthshire and Glamorganshire. Table showing the relation between groups of cases of "post-vaccinal " diseases of the central nervous system and the notifications of (1) poliomyelitis and polioencephalitis, (2) encephalitis lethargica, and (3) smallpox, and also (4) lymph issued for public vaccination, in these areas.

Appendix XVIII.-Analysis of symptoms and physical signs exhibited by the "homogeneous group (47 cases) of the Andrewes Committee and

the 25 cases of the present series.